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Oscar HealthNew
Overview
Perform medical necessity and level of care reviews using clinical judgment and evidence-based guidelines. Coordinate with care providers to assess member conditions and make recommendations on the appropriateness of care.
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Compensation
$35 - $46 / HOUR
Posted
New
Alignment Health
Review prior authorization requests for medical necessity using CMS and MCG guidelines to ensure high-quality, cost-effective care. Collaborate with providers and medical directors to process referrals and manage appeals and grievances.
$77,905 - $116,858 / YEAR
24 days ago
Astrana Health, Inc.
The Case Manager is responsible for coordinating patient care, performing utilization reviews, and establishing discharge plans in collaboration with hospital staff. They must ensure compliance with health plan standards and maintain accurate reporting of inpatient admissions.
$31 - $45 / HOUR
1 month ago
Vantage Search Group
The Registered Nurse will develop and implement a comprehensive utilization management plan to justify medical necessity and analyze healthcare resource utilization. They will act as a liaison between medical staff and insurance carriers while monitoring specialty care referrals for appropriateness and compliance with regulatory standards.
$40 - $44 / HOUR
EL PASO CHILDRENS HOSPITAL CORPORATION
The Utilization Review Nurse monitors hospital services to ensure the appropriateness of admissions and extended stays. They collaborate with physician advisers to support policy development and manage clinical denials related to medical necessity.
Salary not listed
UHS
The RN Care Manager provides comprehensive care management services for medically and socially complex members to improve health outcomes. They are responsible for developing individualized care plans, coordinating care, and fostering partnerships with community resources.
The RN In-Clinic Care Manager provides care management services for medically and/or socially complex members, focusing on achieving optimal health and independence through comprehensive, patient-centered care coordination. This role involves developing individualized care plans, assessing member needs, promoting program knowledge to providers and members, and building partnerships with community resources.
3 months ago
ATC Travelers A
The Case Manager assesses, plans, implements, and evaluates the transition of care for a designated patient population, working within a multidisciplinary team to address medical, financial, and social requirements for discharge.
Larkin Community Hospital
The Case Manager performs and documents patient assessments, manages concurrent reviews, and contacts HMOs daily to obtain insurance authorization for patient admissions and continued stays. Responsibilities also include developing comprehensive plans of care from admission to discharge, ensuring efficient service use, and managing discharge planning coordination with physicians.
WVU Medicine
The role involves collaborating with the Medical Director to reduce care variance, ensure timely discharges, and refer members to appropriate resources. Key duties include assisting in the build and implementation of care management review processes like Prior Authorization and Concurrent Reviews.
Southern California Hospitals
The RN Case Manager performs clinical assessments, utilization reviews, and resource management to ensure safe and cost-effective patient care. They collaborate with the interdisciplinary team to facilitate discharge planning and coordinate transitions of care.
$69 / HOUR
